=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669840336
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOMENTUM PHYSICAL THERAPY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/10/2015
-----------------------------------------------------
Last Update Date | 09/10/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 504 NEW FRIENDSHIP RD
-----------------------------------------------------
City | HOWELL
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07731-2978
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-216-4677
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 504 NEW FRIENDSHIP RD
-----------------------------------------------------
City | HOWELL
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07731-2978
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-216-4677
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICAL THERAPIST/OWNER
-----------------------------------------------------
Name | DR. KATHLEEN MAMMANA
-----------------------------------------------------
Credential | DPT
-----------------------------------------------------
Telephone | 732-216-4677
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | 49QA01131100
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------